The health and care system in Warwickshire has maintained, and strengthened, its ‘discharge to assess’ model through the COVID-19 period by remaining aligned to its core principle of maintaining a person centred Home First approach.
The experience of joint working in a Warwickshire County Council led Better Care Fund project with the local NHS partners’, which remedied poor performance around delayed transfers of care (DTOC), meant that it had a strong foundation from which to respond to COVID-19.
The health and social care partnership had invested significant time and effort over the past two years in understanding the actual flow of their system and how they could make things better, and improve their support to people, including reducing DTOC. Having built these strong relationships, as the pandemic hit, the system was able to have potentially difficult conversations without fear or trepidation. The relationship with their provider market was crucial too, understanding the market, its pressures and the opportunities was a key enabler to their partnership preparedness and response.
Pathway 1: supported discharges
During the COVID-19 response, via their hospital social care teams, the council continued to directly support discharges from the acute trusts under the health pathway of the discharge guidance.
The council’s occupational therapy led reablement service was further adapted from winter to include transitional support, a shorter term offer to people, including those not meeting the Care Act threshold.
The partnership was clear that it wanted to support people leaving hospital quickly, and for their destination to be home, whether via the Community Emergency and Response Team (CERT), reablement or homecare people needed to be back at home. The council had recently introduced PowerBI and has been able to use it to bring insight and support decision making. During the response more Homecare was delivered to maintain people in their own homes Through joint working most people were able to exit hospital at the earliest opportunity via CERT, Reablement or Homecare with peoples’ longer term needs being assessed once they were back home.
Pathway 2: Bedded rehabilitation
Warwickshire has achieved prompt pathway 1 discharges into the community using a Home First strengths based approach not delayed by the need to assess for Care Act eligibility.
Pathway 2 discharges were supported by good availability of beds across the system which are commissioned in the main by the Council. This includes capacity in Extra Care Housing supported by Reablement.
The one commissioner managing the challenges faced by the market on Pathway 2 was really beneficial to flow and unblocking challenges. During the response to COVID-19 Warwickshire managed to continue their downward trajectory of Care Home admissions, cementing and substantiating their person centred Home First approach.
Critical success factors
Warwickshire is evaluating its COVID-19 experience to learn the lessons and strengthen the successful integrated working that has seen people supported to return to their homes.
A number of critical success factors have enabled the system to work effectively and remain aligned to the core principle of maintaining a person centred approach:
- Sustained focus and leadership: developing discharge pathways which embed a person centred approach and a Home First / Discharge to Assess mindset has been a shared priority for over two years
- Market management: The council has worked to develop a buoyant home care market that works and recognises the different geographies and needs.
- In-house reablement: Maintaining and developing an expert in house, council, reablement service that embeds a Home First approach.
- Partnership working: The opportunities afforded by an integrated acute/community provider, South Warwickshire Foundation Trust, and strong partnership working between the Trust and the council have been significant.
- Social work: Maintaining strong social work presence in the hospital has been a key enabler in supporting a proactive Home First approach.
- Integration enables Home First: The Integrated Care System alongside Primary Care Networks are seen as a key enabler to deliver a further embedded Home First culture.
Together this has meant that implications of COVID-19 and associated guidance hasn’t changed the fundamentals, rather it has enabled the principles of a Home First approach to be further embedded.